<div>   
    <div><span style="font-style: italic;" id="editInsuranceMsg" class="formAlertMsg"></span></div>
    <form id="editInsuranceFrm">
        <input type="hidden" name="editInsuranceId" id="editInsuranceId" value="">
        
        <div class="field-row" style="padding-top: 5px;">
            <div class="field-label" style="width: 150px;">{translate}Insurance no{/translate}</div>
            <div id="editInsuranceCode" class="field-value" style="width: 270px; font-weight: bold;">
                    
            </div>  
            <div style="clear: both;"></div>
        </div>
        <div class="field-row" style="padding-top: 5px;">
            <div class="field-label" style="width: 150px;">{translate}Usage time{/translate}</div>
            <div id="editInsuranceDate" class="field-value" style="width: 270px;">
                    
            </div>
            <div style="clear: both;"></div>
        </div>
        <div class="field-row" style="padding-top: 5px;">
            <div class="field-label" style="width: 150px;">{translate}Registered hospital{/translate}</div>
            <div id="editInsuranceRegisteredHospital" class="field-value" style="width: 270px;">
                
            </div>
            <div style="clear: both;"></div>
        </div>
        
        <div class="field-row" style="padding-top: 10px;">
            <div class="field-label" style="width: 150px;">&nbsp;</div>
            
            <div class="field-value" style="width: 150px;">
                <input type="checkbox" id="editCorrectRoute" checked="checked" /> <span style="font-weight: bold; color: #3B87C5;">{translate}Correct route{/translate}</span>                
            </div>            
                         
            <div class="field-value" style="width: 200px;">
                <input id="editPaidFor36Month" type="checkbox"> <span style="font-weight: bold; color: #3B87C5;">{translate}Lien tuc 36 thang{/translate}</span>
            </div>
            
            <div style="clear: both;"></div>
        </div>
	</form>
</div>